FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

g l„ � �� i • FILE COPY "ENVIRONMENTAL JOAQUIN COUNTY _`• -^"'—. .y APR ENVIRONMENTAL HEALTH DEPARTMENT Lop Frli9L �'Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION V P ') 9)468-3147 Fax:(209) 468-3433 Web:wwwsiaov.org/ehd UNIT IV i eo- EN PE• WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance Wth San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. O� Site Location I�Z4) 61eVcn-t1, 'Sf Cross Street A'GC"u( 1Gf Ve- City/State TaCZip`�j 37(� APN 7-5D Property M (� 1 p 2 Owner 1'1 t f CL Pia,d.r 11& Address?,i% UM. I O&P City/State Zip 7 Phone C-57 Contractor Ua0rWj&xP.r"A/&jNddress .5CO M,41/ / S>26'/ City/State 0WO is 571sPho eS/O'a3&—,'o-24Z ConsultantlSub Cntr Address City/State Lic Phone Billable Party 4,yr Address 4P?00 City/State nCkt7 Zip `)SZn7U Phone'?/&- 39Y-07 10 GIS Coordinates:X CONSTRUCTION WORK TO BE PERFORMED: t&NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAJJD-AUGER,OTHER) SOIL BORING IDs 67J9-1, 0-R-1 Ei P'�ii hQ' LFF At VId P�� WELL IDs ❑ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z11 ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _O EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE 5 IkSOIL BORING ! PUSH POINT(GP/CPT) GROUT SEAL PUMPED;0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Nr Soame.Ozone)0 HAND AUGER GROUT SPECIFICATIONS _0 OTHER: ❑OTHER: APPROX.BORING DEPTH ZO 1 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Bodng Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:/CHECK ALL THAT APPLY) _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regula ' ns,and all a licable California laws. ft �l� r��! r Signed - Title/Company ft2c'f flp'?d4a �✓ f flrt/✓1�P� Jw 77Y/r Print Na a Va J SP/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS #710 G - Et 6LA-,0T-* 57- . WORK PLAN DATED I/- t9 Y.U/ t!fi APPLICATION ACCEPTED BY .) 01l"'1 go✓YKWrr't DATE WEA �4Q GROUT INSPECTION BY FINAL INSPECTION BY DATE 8-/-/.3 DESTRUCTION INSPECTION BY DATE COM M E NTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE PRO: INVOICE REQUEST zoos $ 125, ( / -�/ (2C)U# W 4/46-/3 SR# 00fv 2�o 3 375 3500 PR# 2900 C-57 ✓ WC WAIVER IU 4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �i ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP